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GYMNASTIC ACADEMY OF BOSTON—ACTON
SUMMER CAMP PACKET 2015
12 Keefe Rd. Acton, Ma 01720 ● Phone: 978-369-9034 ● E-mail: [email protected] ● GymnasticAcademyofBoston.com
Welcome to GAB Summer Camp, we have a lot of fun and excitement planned this year! Enclosed in this packet you will find:
● Sample Daily Schedule, What To Bring, Food Allergy Policy
● Camp Policies & Procedures
● Camp Liability Waiver
● Medical History Form & Medication Form
● IMPORTANT, updated Physical & Immunization Forms are needed for each camper from your Primary Physician’s office.
The forms in this packet must be filled out and returned to our office before your child attends camp. GAB is a Board of Health licensed summer camp, and this is a Board of Health requirement that this camp must comply with. The Parent/Legal Guardian is
responsible for all the forms and information within this packet.
Daily Sample Camp Schedule:
7:30-9:00 am—Extended Day (optional)
9:00 am—Camp begins
9:00-10:00 am—Warm-up/ Activities/ Gymnastics Lesson
10:00-10:15 am—Snack Time
10:15-11:00—Arts’n Crafts/ Games
11:00-12:00—Gymnastics Lesson
NOON—Morning Session Ends
NOON-12:30 pm—Lunch time for Full Day Campers
12:30 pm—Afternoon Session Begins
12:45-1:45 pm—Free Swim at TeamWorks-Acton
1:45-2:30 pm—Return to GAB, snack time
2:30-3:30 pm—Warm-up/ Activities/ Gymnastics Lesson
3:30 pm—Afternoon Session Ends
3:30-5:30 pm—Extended Day (optional)
What to Bring:
AM CAMPERS (9am-12pm):
 Gymnastic clothes
 Snack & Drink
PM CAMPERS (12:30-3:30pm):
 Swimsuit, Sunscreen*, Towel
 Gymnastic clothes
 Snack & Drink
* Spray On sunscreen is highly recommended
FULL DAY CAMPERS (9am-3:30pm):
 Gymnastic clothes
 2 Snacks, 1 Lunch, and Drinks
 Swimsuit, Sunscreen, Towel
Please do not drop off
campers without shoes/
sandals! A set of extra clothes
is always a good idea!
Please label all your child’s
belongings to prevent loss!
Food Allergy Policy
 Gymnastic Academy of Boston (G.A.B.) recognizes that food allergies, in some instances, may be severe and even occasionally lifethreatening. The foods most likely to cause allergic reactions are peanuts, tree nuts, dairy products, eggs, soy, wheat, fish, and shell-fish.
Although most food allergies produce symptoms that are uncomfortable, persons with allergies to the above-listed foods can suffer more
serious consequences.
 -G.A.B. would like to support you in your endeavors to make the world a safer place for our children and has created this policy to reduce the
likelihood of severe allergic reactions of students with known food allergies while in our care.
 G.A.B. would like to ask all of our members and non-members to help G.A.B. become a facility that is a Food Allergy Aware Zone. Please, be
aware that as of today we are not a Food Allergy Free Zone, but we are hoping that with your support we will bring a high level of awareness
to this matter and make our facility safer to your children.
 Parents of students with life-threatening allergies must provide G.A.B. with emergency medications and a written medical treatment protocol
for their student for addressing allergy-related events. G.A.B. will keep medication and epinephrine (EpiPen) provided by student’s guardian
in a secure location where the Health Administrator can access it when necessary.
 Information pertaining to a student's allergies will be shared with G.A.B. staff that have contact with the student, but otherwise will be kept as
confidential as possible.
 Peanut allergies are among the most common. Accordingly, G.A.B. will educate all member and non-member costumers about the awareness of food allergies and encourage all students and families to provide lunch and snacks that are free of nuts to ensure the student's
safety.
 G.A.B. will work with all member and non-member costumers to reduce the likelihood that peanuts, tree nuts, or nut oil products are brought
in to our facility during classes, birthday parties and/or camps.
 G.A.B. requires that all staff and students wash their hands before and immediately after eating.
 G.A.B. Though G.A.B is committed to student safety we cannot guarantee that a student will never experience an allergy-related event while
in our care, and therefore has created this policy to reduce the risk that children with allergies will have an allergy-related event.
Camp Policies & Procedures
This camp must comply with regulations of the Massachusetts Department of Public Health and be licensed by the Board of Health.
Registration Policies
 Our camp has open registration throughout the summer; spaces are limited!
 Ages 3-6 may register for single days of camp; ages 7+ must enroll for the full week.
Payment & Refund Policy
 There are NO REFUNDS given once you have turned in the Registration Form with your payment.
 Registrations will not be processed without payment in full for your first week of camp. Additional weeks must be paid in full by June 25,
2014.
 You may change the week your camper is enrolled on a space available basis only.
 Cash or Check only please!
Sign In/ Sign Out
 All campers must be signed in and out when they are dropped off and picked up.
 If a camper is dropped off before 8:45 am, or picked up after 3:30 pm, there will be a $20 extra charge for extended day.
 Campers are NOT allowed to sign themselves in or out, regardless of age.
 A camper will not be released to someone who is not their parent/guardian, or who is not listed on the Camper Release Form.
Camper Requirements
 GAB reserves the right to remove a camper if that camper poses a safety threat to staff members or other campers.
 All campers must be age 3+, and must be fully potty-trained.
 All campers must be paid in full and must have all forms returned to the office by their first day of camp.
 Campers must abide by all GAB Summer Camp rules.
Staff Requirements
 All staff must have CORI/SORI background checks before working at our Summer Camp.
 All staff will go through training, and full-time staff are CPR and First Aid Certified.
 Staff must be up to date on their immunizations.
Extended Day
 Extended day is offered on a weekly basis only.
 Extended day is located in the upstairs room of GAB. We do not use the gym or engage in any gymnastics during this time.
 A fee of $8 per 15 min. will be charged for any child picked up after 5:30 PM.
Swimming & Sunscreen
 Free swim time at TeamWorks-Acton is monitored by both GAB Staff, and by the lifeguards employed by TeamWorks.
 All campers must pass a swim test before being able to go in the deep end of the pool.
 Campers will walk to and from the pool under the supervision of our Staff. Footwear must be worn.
 All campers must have sunscreen* applied before going outside. Staff will help campers apply sunscreen* if needed.
* Spray On sunscreen is highly recommended as it aids in a much more efficient changing time
Emergency Policy
 Once a week, a mock fire drill will be performed so all campers are familiar with procedure and exit strategies.
 In the event of an emergency, the Camp Director will blow a whistle signaling to Staff to evacuate their campers from the building.
 Staff will bring all campers to designated safe areas outside the building while the problem is resolved.
Sick Camper Policy
 Mildly sick campers can lie down in a designated quiet area in our facility.
 The Camp Director will determine if a camper is too sick to stay at camp, and will call the parents/guardians to come pick up their sick
camper if needed.
 In the event of a serious illness or injury, if the parent/guardian cannot be reached in time, the camper may be transported to Emerson Hospital for immediate care and treatment.
Other Policies
 All snack and lunch times are monitored by Staff members. Campers are not allowed to share food or drink.
 Staff are to make sure that enough water breaks are given during hot days.
 Staff may not discipline a camper for having an accident.
 Timeouts will be given if a camper breaks a camp rule. Parents may be called if there is an ongoing issue, and the camper may be removed
from camp if necessary.
GAB SUMMER CAMP 2015
AUTHORIZATION, WAIVER & RELEASE FORM
To be completed by parent or legal guardian.
CAMPER NAME______________________ ______________________
Last
First
2ND CAMPER: ______________________ ______________________
Last
First
BIRTHDATE_____/_____/_____ SEX______ AGE_______
BIRTHDATE_____/_____/_____ SEX______ AGE_______
PARENT/GUARDIAN NAME________________________________________ HOME PHONE_____________________________
ADDRESS_______________________________________________________ CELL PHONE_____________________________
________________________________________________________________ WORK PHONE_____________________________
EMERGENCY INFORMATION
IN THE EVENT OF AN EMERGENCY, PLEASE NOTIFY:
1. NAME_________________________________ RELATION_______________________ PHONE_____________________________
2. NAME_________________________________ RELATION_______________________ PHONE_____________________________
WAIVER/ RELEASE:
I hereby agree that neither Gymnastic Academy of Boston, Inc., nor its agents, employees, officers or directors shall be liable for any injuries
which are in any way related, whether directly or indirectly, to my child’s participation in gymnastics, swimming, special activities (including, without limitation, birthday parties) or other activities. I am fully aware of the risks, including the potential for personal injuries, damages or losses
associated with participation in the sport of gymnastics and in swimming, and I assume all risks and accept full responsibility for any injury, damages or losses which my child may incur in connection with my decision to enroll in camp.
I also hereby authorize Emerson Hospital, its doctors and the Gymnastic Academy of Boston, Inc. camp staff to act for me according to their best
judgment in any emergency requiring medical attention. It is understood that in the case of serious illness or injury the parents or guardians of
the student will immediately be notified by telephone. When such communication shall fail or when delay may endanger the camper, Gymnastic
Academy of Boston, Inc. camp or anyone appointed by the camp shall have the authority to permit hospitalization, any emergency or surgical
procedure and the use of anesthesia. I hereby waive and release Gymnastic Academy of Boston, Inc. camp, its
doctors and hospitals, including Emerson Hospital from any and all liability from any injuries, illnesses or medical attention incurred or received
going to camp, while at camp or returning from camp.
Parent/Guardian Signature_______________________________________Date____________________
FULL DAY/AFTERNOON CAMPERS ONLY:
_______________________________________has my permission to be transported to swimming as part of the camp program.
(campers name)
Parent/Guardian Signature_______________________________________Date____________________
DROP-OFF / PICK-UP FORM
SUNSCREEN FORM
Spray On sunscreen is Highly Recommended
I hereby authorize the following person(s) to drop off and/or pick up my
child(ren) from GAB Summer Camp:
I hereby authorize the Gymnastic Academy of Boston to apply
Full Name__________________________ Phone ________________
________________________________ to my child(ren)
type of sunscreen
Full Name__________________________ Phone ________________
Full Name__________________________ Phone ________________
—————————————–—————————————
Signature of Parent/Guardian
—————————————————–
Date
______________________________________________ if needed.
camper name(s)
————————————–—————————————
Signature of Parent/Guardian
—————————————————–
Date
Camper Medical History
This form must be filled out by the parent/guardian.
In addition to this document, each camper must have a form from their physician of
immunizations and a physical exam within the past year.
Last exam date:____/____/____ Examined by:______________________ (Signature not required)
Family Physician:________________________________ Phone (_____)_______-___________
Physician’s Address: _______________________________ Town:________________________
Please list previous and current health conditions, including Nervous System/Mental Disorders:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
List all previous surgeries and dates: _______________________________________________
_____________________________________________________________________________
List all allergies: _______________________________________________________________
_____________________________________________________________________________
Prescription Drugs: This includes inhalers and EpiPens.
*All prescriptions must be in their original containers with information regarding the prescriber, the
patient, and general dosage.*
_____________________________________________________________________________
_____________________________________________________________________________
My child is healthy enough to participate in any and all activities at the Gymnastic Academy of
Boston’s Summer Camp.
_________________________________
Parent/Legal Guardian Signature
__________________
Date
AUTHORIZATION TO ADMINISTER MEDICATION
This form must be filled out by the parent/guardian.
Name of Camper_____________________________
Parent/Guardian Name:_________________________
Food/Drug Allergies:_________________________
Home Phone (_____)_________-________________
Diagnosis (at parents discretion):________________
Work Phone (_____)_________-________________
Cell Phone (_____)_________-________________
Name of Licensed Prescriber:___________________________________ Phone (______)________-_____________
Name of Medication:__________________________ Dose given at camp:________ Route of Administration________
Frequency:___________ Date ordered:__________ Duration of Order:___________ Quantity received:____________
Expiration Date of Medications Received:_____________ Special Storage Requirements:_______________________
Specific Directions (e.g., on empty stomach/with water):__________________________________________________
Specific Precautions:______________________________________________________________________________
Possible Side Effects/Adverse Reactions:______________________________________________________________
Other medications (at parents discretion):______________________________________________________________
Location where medication administration will occur:_____________________________________________________
I hereby authorize The Gymnastic Academy of Boston to administer, to my child ______________________________ ,
(NAME OF CHILD)
the medication(s) listed above, in accordance with 105 CMR 430.160.
105 CMR 430.160(A)
Medication prescribed for campers shall be kept in original containers bearing pharmacy label, which shows the date of filling, the pharmacy name and
address, the filling pharmacist’s initials, the serial number of the prescription, the name of the patient, the name of the prescribing practitioner, the name of the
prescribed medication, directions for use and cautionary statements, if any, contained in such prescription or required by law, and if tablets or capsules, the number in the container. All over the counter medications for campers shall be kept in the original containers containing the original label, which shall include the directions for use.
105 CMR 430.160 (C)
Medication shall only be administered by the health supervisor* or by a licensed health care professional authorized to administer prescription medications. The health care consultant shall acknowledge in writing the list of medications administered at the camp. If the health supervisor is not a licensed health
care professional authorized to administer prescription medications, the administration of medications shall be under the professional oversight of the health care
consultant. Medication prescribed for campers brought from home shall only be administered if it is from the original container, and there is written permission
from the parent/guardian.
105 CMR 430.160 (D)
When no longer needed, medications shall be returned to a parent or guardian whenever possible. If the medication cannot be returned,
it shall be destroyed.
*Health Supervisor—A person who is at least 18 years of age, specially trained and certified in at least current American Red Cross First Aid (or its equivalent) and CPR, has been
trained in the administration of medications and is under the professional oversight of a licensed health care professional authorized to administer prescription medications.
Parent/Guardian Signature: ________________________________________ Date: _________________